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Crossing the field's quality chasm

January 1, 2006
by EDWARD R. JONES, PHD
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The Institute of Medicine offers recommendations on what needs to be done to improve service delivery

The Institute of Medicine (IOM) released an important report on behavioral healthcare on November 1, 2005, titled Improving the Quality of Health Care for Mental and Substance-Use Conditions. Yet as the report's title reflects, the committee that drafted the report abandoned the term “behavioral healthcare.” The committee decided to use the acronym “M/SU” to refer to “mental and substance use” throughout the report. Whether or not M/SU becomes the commonly accepted designation, many will welcome the suggested elimination of a term that consumers rarely understand.

The M/SU report is essentially a long overdue follow-up to the IOM's 2001 report titled Crossing the Quality Chasm: A New Health System for the 21st Century. The 2001 report establishes a strategy for improving healthcare overall, but it does not specifically address the unique issues related to the care of M/SU conditions. The new report essentially starts with the framework for quality improvement established by the 2001 report and then develops an adaptation for mental health and addictive disorders.

The IOM has established a rigorous process for developing its reports, and it starts with the selection of a committee, with members chosen for their diverse perspectives and technical expertise. Mary Jane England, MD, president of Regis College (Weston, Massachusetts), served as chair of the 22-member M/SU committee; Dr. England is a child psychiatrist and former president of the Washington Business Group on Health, bringing expertise as both a physician and healthcare policy leader. The committee heard testimony from various stakeholders in the care of M/SU conditions, and a draft report was produced by IOM staff.

The draft report was reviewed by 11 other individuals who were likewise selected for their diverse perspectives and technical expertise. I was fortunate enough to be selected as one of these reviewers. The reviewers are asked to provide candid and critical comments, which are sent confidentially to the IOM for deliberation. The goal is for the final report to meet the IOM's standards for objectivity, evidence, and responsiveness to the study charge.

The 2001 report identifies six aims of high-quality healthcare: It should be safe, effective, patient-centered, timely, efficient, and equitable. These aims were found to be equally relevant for M/SU care, and the M/SU report articulates the many ways in which we are falling short of these aims today. The 2001 report also identifies ten rules to guide the redesign of healthcare, and the M/SU committee determined that these rules can provide the guidance needed for redesigning M/SU care, as well.

The M/SU report succinctly states the many differences between M/SU healthcare and general healthcare:

The M/SU report does an excellent job of describing the many problems with M/SU care but, more importantly, it provides a number of detailed recommendations for how to rectify those problems. These recommendations are directed at all stakeholders in M/SU care, including clinicians, provider organizations, health plans, governmental agencies, and national purchaser associations. It is not possible to summarize the many recommendations in the report in a short article, so instead just one recommendation is described here to demonstrate the nature of these recommendations.

Recommendation 4-2 states that clinicians and organizations providing M/SU services should:

  • Increase their use of valid and reliable patient questionnaires or other patient- assessment instruments that are feasible for routine use to assess the progress and outcomes of treatment systematically and reliably.

  • Use measures of the processes and outcomes of care to continuously improve the quality of the care they provide.

This single recommendation has the ability to significantly transform care. It highlights the fact that clinicians always should be asking a key question during the course of a treatment episode: Is the treatment I am providing helping this patient? The answer to this question cannot be based simply on the treating clinician's judgment. We need to go directly to the patient to understand treatment response, using patient self-report questionnaires much like a physician uses lab tests to monitor various aspects of health status.

This recommendation calls for these measures to be used in a routine way so that we can assess progress systematically. In other words, this recommendation goes well beyond common practice today. Currently, patient questionnaires are used sporadically and rarely serve to inform the treatment process as it is occurring. The IOM is essentially calling for the measurement of clinical outcomes to be incorporated into the care-delivery process. The idea is that care should be outcome-informed, irrespective of the specific treatment being provided. While the M/SU report strongly advocates the use of treatments with a strong evidence base for their effectiveness, recommendation 4-2 pushes us further because we cannot assume that every patient will respond positively to evidence-based practices.

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